Average — CMS composite of the measures below.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at St Francis Health Services during CMS and state inspections, most recent first.
Pressure injuries were not accurately assessed, staged, or consistently treated for two residents. One resident at high risk for skin breakdown developed bilateral heel DTIs that progressed, while ordered heel protection and dressing interventions were not consistently reflected in the care plan or CNA Kardex and the heels were observed covered only with white tape instead of the ordered dressings. Another resident’s coccyx wound was staged incorrectly despite necrotic tissue and exposed muscle, and the coccyx and right heel wounds were not comprehensively assessed on a weekly tracking date.
A facility failed to complete the required four-year BID, DOJ response, and IBIS letter for one SS staff member. Record review showed the staff member’s prior background screening was completed in 2021, but the next screening was not completed until the survey began, and the NHA acknowledged the four-year timeline had been missed.
Medication storage was not maintained according to facility policy when a medication room door was observed wide open and propped with a doorstop, leaving medication packages easily accessible. An LPN stated the door should not have been left open and that only nurses and the DON had keys. The vaccine refrigerator was also found at 30 degrees Fahrenheit with frost buildup, and later at 40 degrees Fahrenheit with continued frost buildup; the LPN was unsure of the proper temperature range, and the influenza vaccines were later discarded after pharmacy indicated they were likely affected by potential freezing.
A resident with Alzheimer’s disease, dementia, anxiety, depression, and CHF enrolled in hospice, but the facility did not complete the required SCSA MDS within the required timeframe. Survey review found the MDS was completed about a month later, and an MDS LPN stated the delay occurred because the hospice enrollment was missed while coverage was being provided by another coordinator.
A resident was discharged to the hospital after worsening pain, abnormal vital signs, decreased responsiveness, and oxygen use. The resident’s DCRA MDS was completed but not submitted to the State within the required timeframe, and review of submitted batches showed it was not included.
A resident with documented hearing loss and MDS-coded hearing aid use was observed to be very hard of hearing and not wearing hearing aids. The resident said the hearing aids had disappeared, while staff gave conflicting accounts about whether the devices were broken, being repaired, or with the VA/Hospice. The chart lacked hearing aid orders, and the care plan did not clearly address the resident's hearing aids or communication needs until after survey review.
Failure to Individualize Bladder Incontinence Care: A resident with diagnoses including intracerebral hemorrhage, epilepsy, dementia, and psychosis had a documented decline from frequent urinary incontinence to always being incontinent of urine. The annual MDS noted no toileting program, prompted voiding, or bladder training had been attempted, and later quarterly MDSs and the care plan did not include individualized bladder interventions such as trial voiding patterns. The CNA care card also lacked bladder incontinence interventions, and the DON could not provide additional information about the resident’s bladder assessments.
Failure to Follow EBP During Catheter Care: A resident with a Foley catheter, urinary retention, and intact cognition was observed during catheter care when a CNA did not perform hand hygiene before donning gloves and did not wear a gown, despite EBP being in place and posted on the room door. The CNA said she was not aware a gown was required, and both an LPN and the DON stated that gown and glove use was expected for catheter care.
A resident reported that a visitor yelled at and shook her, and may have previously taken money. While the incident was reported to the police and staff were instructed to prevent the visitor from returning, the facility did not interview staff or other residents as part of the investigation, contrary to policy requirements.
The facility did not accurately calculate or analyze infection rates, as the DON included ongoing and chronic infections in monthly counts and did not separate facility-associated from community-based infections. Infection surveillance reports lacked calculations for individual infection types, and no policy or standard practice for infection rate calculation was provided.
A resident with severe cognitive impairment and a history of falls experienced three unwitnessed falls that were not thoroughly investigated to determine root causes. Documentation was incomplete, lacking details on toileting and incontinence status, and interventions such as increased toileting assistance were delayed. The facility's response did not align with its own policies for hazard identification and timely intervention.
A resident with dysphagia and a physician-ordered pureed diet was served a banana that was only cut in half and left in the peel, rather than being pureed as required. The facility's dietary guidelines and the resident's care plan specified that all foods, including bananas, must be pureed to ensure safe consumption. Staff confirmed the error after it was observed by a surveyor, and the uneaten banana was found on the resident's bedside table.
A resident on a mechanically-altered diet was served pureed foods at temperatures below the required 135°F, and kitchen staff failed to follow proper hand hygiene protocols by not washing hands between glove changes or after handling kitchen equipment, contrary to facility policy.
Pressure injuries were not accurately assessed, staged, or consistently treated
Penalty
Summary
The facility did not ensure that two residents with pressure injuries or at risk for pressure injuries received care and services consistent with professional standards of practice. One resident was dependent for all care, required substantial to maximal assistance with bed mobility, and was identified as at risk for pressure injuries. The resident’s care plan included general skin interventions, but the order for soft boots while in bed was not included in the care plan or CNA Kardex, and several pressure injury tracker interventions were also not reflected in the care plan or CNA Kardex. The resident developed bilateral heel deep tissue injuries after admission, and the right heel later progressed to an unstageable pressure injury with increasing size and changing wound characteristics. Surveyor observation on 2/18/2026 found the resident’s bilateral heels covered only with white tape rather than the ordered dressings. The DON stated the correct dressings were not in place and that foam dressings should have been used. The surveyor also observed the right heel wound as dark purple/black and non-blanchable, while the wound tracker documented the right heel as an unstageable injury with necrotic tissue and the left heel as a suspected DTI. The record showed the right heel wound had enlarged and the left heel wound had also increased in size after the resident returned from the hospital. Staff gave differing explanations about the cause of the heel injuries, including possible self-propelling in the wheelchair, but no documentation or evidence was provided to show the facility addressed that concern or documented related interventions. A second resident was admitted with pressure injuries to the coccyx and right heel. The admission documentation and weekly wound tracking did not consistently or accurately stage the coccyx wound, which was documented as a Stage 3 despite records showing necrotic tissue and exposed muscle. The coccyx and right heel wounds were not comprehensively assessed on one weekly tracking date, and the wound clinic consult sheets did not document wound assessments. On a later observation, the coccyx wound was measured and described differently than earlier documentation, and the right heel wound was again assessed as unstageable with eschar. The surveyor and DON discussed that the coccyx wound should have been documented as unstageable, and the DON acknowledged that the wounds should have been assessed on the date they were not comprehensively documented.
Missed Four-Year Background Check for Social Services Staff
Penalty
Summary
The facility did not ensure that it did not employ individuals found guilty of abuse, neglect, exploitation, or mistreatment because it failed to complete a background information disclosure every four years for one Social Services staff member, SS-G. The facility policy on Abuse, Neglect, and Exploitation states that background checks, including re-checks, are to be completed consistent with applicable state laws and regulations, and that the facility will maintain documentation showing the screening occurred. During record review on the first day of survey, the surveyor reviewed employee files for 8 randomly selected staff and found that SS-G, who had a hire date of 12/1/2016, had a BID form, DOJ response, and IBIS letter dated 2/16/26. The surveyor noted this was the start date of the survey and the date the BID was requested from the NHA. The NHA stated that SS-G’s prior BID, DOJ response, and IBIS letter had been completed in 2021, and provided those records, which showed a completed date of 4/26/2021. When the surveyor raised concern that the required four-year timeline had been missed, the NHA acknowledged that the four-year timeline was missed for SS-G.
Medication Room Left Open and Vaccine Refrigerator Improperly Stored
Penalty
Summary
Medication storage was not maintained in accordance with facility policy and procedures in 1 medication room reviewed. During observation on 2/17/2026 at 7:29 AM, the surveyor saw the medication room door wide open and propped open with a doorstop, with an open plastic bin containing medication packages easily accessible. During medication pass, an LPN went to the medication room to retrieve medication, closed the door, and stated the door should not have been left open and that she was unsure who left it that way. She also stated that only nurses and the DON had keys to the medication room. Later that day, the surveyor observed the vaccine refrigerator in the medication room reading 30 degrees Fahrenheit with frost buildup inside. The facility policy stated medication rooms, cabinets, and supplies should remain locked when not in use or attended by authorized persons, and that the refrigerator should be kept clean and frost-free. The LPN was unsure what the proper temperature range should be. On 2/18/2026, the DON and surveyor again observed frost buildup in the vaccine refrigerator, which then read 40 degrees Fahrenheit. The facility later reviewed the refrigerator issue with pharmacy, and the influenza vaccines in the refrigerator were discarded after pharmacy indicated they were likely affected by potential freezing.
Late Significant Change MDS After Hospice Enrollment
Penalty
Summary
The facility did not complete a Significant Change in Status Assessment (SCSA) Minimum Data Set (MDS) for a resident who enrolled in hospice services. The Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User’s Manual states that an SCSA is required when a terminally ill resident enrolls in hospice, and the Assessment Reference Date must be within 14 days of the effective date of the hospice election. The resident, who had diagnoses including Alzheimer’s disease, dementia, anxiety, depression, and congestive heart failure, was evaluated by hospice and re-admitted to hospice services on 12/26/25. A progress note dated 12/29/25 documented that the resident had been evaluated by hospice and re-admitted to services that day. Survey review found an SCSA MDS dated 1/26/26 in the resident’s EHR, which was completed after the hospice enrollment date. During interview, the MDS LPN stated that a significant change MDS would normally be completed within 7 days when a resident enrolls in hospice, but said this resident’s assessment was late because the MDS LPN was off, another MDS coordinator was covering, and the change was missed. The NHA, DON, and President of Success were informed of the concern, and no additional information was provided.
Failure to Submit Completed Discharge MDS Assessment
Penalty
Summary
The facility failed to transmit R19’s discharge assessment to the State within 7 days after completion. R19 was admitted after hospitalization for acute on chronic neck pain and was discharged to the hospital on 8/30/2025 after nursing documented that the resident was in bed with complaints of neck and back pain, was not responding as normally, had abnormal vital signs, was placed on 3 liters of oxygen, and was transferred to the hospital. R19’s Discharge Return Anticipated (DCRA) MDS assessment was completed but not submitted. During an interview on 2/17/2026, the MDS LPN reviewed the record and agreed the assessment was coded as completed but not accepted, and that it was not included in any of four batches of assessments submitted during that timeframe. The VP of Clinical Reimbursement was contacted and agreed the assessment had not been submitted. The NHA and DON were later informed that the assessment had been missed.
Failure to Ensure Access to Hearing Aids and Hearing Services
Penalty
Summary
The facility did not ensure a resident with hearing impairment received proper treatment and assistive devices to maintain hearing abilities. The resident was admitted with COPD, had a BIMS score of 15 indicating cognitive intactness, and the annual MDS documented that the resident had adequate hearing and used hearing aids. During survey observation, the resident was very hard of hearing and was not wearing hearing aids, and the resident stated the hearing aids had disappeared. Record review showed a prior audiology consultation documenting bilateral hearing loss and recommendations for daily cleaning of the hearing aid microphones and monthly or as-needed wax guard changes for the left hearing aid. However, the order summary contained no orders regarding the hearing aids, and the care plan only addressed speaking into the left ear as the better ear. Staff interviews reflected uncertainty about the location and status of the hearing aids, with one LPN stating one hearing aid had been broken for about 6 months and a CNA stating they were in the process of being fixed. The DON and MDS Coordinator acknowledged that the resident should have had a hearing-related care plan and that the annual MDS indicated hearing aids, while the resident's hearing care was not clearly reflected in the care plan at the time of survey.
Failure to Individualize Bladder Incontinence Care
Penalty
Summary
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections was not consistently met for one resident reviewed for urinary incontinence. The resident was admitted with diagnoses including nontraumatic intracerebral hemorrhage, epilepsy, dementia, mood disorder, hypertension, hyperlipidemia, and unspecified psychosis. The most recent annual MDS documented frequent urinary incontinence and noted that a toileting program, prompted voiding, or bladder training had not been attempted. The urinary incontinence and indwelling catheter CAA was triggered by the resident’s need for toileting assistance, impaired mobility, dementia, and incontinence, and the facility indicated urinary incontinence would be addressed on the care plan with the objective of improvement and avoiding complications. Subsequent quarterly MDS assessments documented that the resident became always incontinent of urine, and no toileting program for bladder was documented. The care plan noted incontinence related to cognitive deficit secondary to neurological deficit and decreased mobility, with interventions to attain or maintain continence based on usual voiding pattern and provide toileting assistance as needed, but it did not include individualized interventions such as trial voiding patterns. The CNA care card did not document bladder incontinence interventions. During survey review, the facility provided a quarterly clinical review showing the resident was incontinent of bladder, wet 1-2 times daily during the day and nighttime, and the DON was unable to provide additional information about the bladder assessments or explain the resident’s decline in urinary continence.
Failure to Follow Enhanced Barrier Precautions During Catheter Care
Penalty
Summary
The facility did not maintain an infection prevention and control program designed to reduce the transmission of disease and infection for 1 resident with an indwelling urinary catheter. The resident had diagnoses including chronic kidney disease with heart failure, urinary retention, and benign prostatic hyperplasia with lower urinary tract symptoms. The resident’s MDS documented a BIMS score of 15, indicating intact cognition, and documented dependence for toileting hygiene and the presence of an indwelling urinary catheter. The resident’s care assessment documented that the resident had a Foley catheter related to urinary retention, and the care plan included enhanced barrier precautions and changing the urinary collection bag as needed. Physician orders directed catheter care every shift and as needed, and enhanced barrier precautions every shift due to the Foley catheter. During observation of catheter care, a CNA exited the resident’s room to obtain alcohol wipes, returned, and donned gloves without performing hand hygiene. The CNA then completed emptying the catheter without donning a gown, despite an enhanced barrier precautions sign posted on the resident’s door stating that staff must clean their hands before entering and when leaving the room and must wear gloves and a gown for urinary catheter care. The CNA stated she was not aware a gown was supposed to be worn. An LPN stated that a resident with a catheter should be on enhanced barrier precautions and that staff would be expected to wear a gown and gloves when performing catheter care. The DON also stated that a CNA should wear a gown and gloves when doing catheter care and follow enhanced barrier precautions. The surveyor informed the NHA of the observations, and no additional information was provided.
Failure to Conduct Thorough Investigation of Alleged Visitor Abuse
Penalty
Summary
The facility failed to ensure a thorough and properly documented investigation regarding an alleged visitor-to-resident altercation involving one resident. According to the facility's policy, investigations of alleged abuse must include identifying and interviewing all involved persons, including the alleged victim, perpetrator, witnesses, and others who might have knowledge of the allegation. In this case, the resident reported that a friend and former caregiver visited her, yelled at her, shook her by the arms, and may have previously taken money from her. The incident was reported to the social worker by a CNA, and the police were contacted to take the resident's statement. The facility also posted a notification to staff to prevent the friend from visiting the resident. However, the investigation did not include interviews with facility staff who may have had relevant information about the incident, nor were any other residents interviewed. The administrator stated that staff were not interviewed because the incident did not involve facility staff, and the social services director confirmed that no other residents were interviewed as there were no witnesses. The resident was assessed and found to have no physical marks and continued to participate in meals, therapy, and activities without ill effects. The lack of comprehensive staff interviews and documentation of the investigation process constituted a failure to follow the facility's abuse investigation policy.
Failure to Accurately Calculate and Analyze Infection Rates
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by inaccurate calculation and analysis of infection rates. The Director of Nursing (DON), who oversees the infection control program, reported that individual rates of infection were not calculated, and infections were counted in multiple months if they persisted or were chronic. Additionally, the DON did not distinguish between facility-associated and community-based infections when compiling infection data. Monthly infection surveillance reports reviewed from October 2024 to March 2025 only included the number of infections, without calculations for each type of infection, and combined both community and facility-associated infections in the total rates. Further review of the facility's infection surveillance logs revealed that infections from previous months and chronic infections, such as those due to multiple drug-resistant organisms, were included in the infection rates. When asked, the DON was unable to provide a facility policy or standard practice for calculating infection rates. The surveyor notified the Nursing Home Administrator and the DON of these findings, and no additional information or justification was provided for the lack of proper infection rate calculations or the failure to use only new, healthcare-associated infections in the infection rate data.
Failure to Investigate and Address Causes of Multiple Resident Falls
Penalty
Summary
The facility failed to ensure adequate supervision and thorough investigation of falls for a resident with a history of multiple unwitnessed falls. The resident, who had severe cognitive impairment, incontinence, and multiple diagnoses including dementia and psychosis, experienced three unwitnessed falls. Each fall was not thoroughly investigated to determine the root cause, and interventions were not promptly or appropriately updated to address the underlying issues. For example, after a fall related to toileting needs, the care plan was not revised to increase toileting assistance until two months later. Documentation and post-fall assessments lacked critical information, such as the resident's incontinence status at the time of each fall, the timing of the last toileting, and whether the resident had the capacity to use a call light for assistance. In one instance, the intervention implemented was to provide a different type of call light, despite staff interviews indicating the resident did not use the call light intentionally. Additionally, there was confusion and lack of clarity in documentation regarding the use of assistive devices, such as whether a walker or wheelchair was in use at the time of a fall. Interdisciplinary team meetings were held after each fall, but the interventions developed were not always based on a thorough root cause analysis. The facility's own policy required systematic identification, evaluation, and analysis of hazards and risks, as well as timely implementation and communication of interventions. However, the investigation and documentation following each fall did not consistently meet these standards, resulting in missed opportunities to prevent further incidents.
Failure to Provide Pureed Food as Ordered for Resident with Dysphagia
Penalty
Summary
A deficiency occurred when a resident with a physician-ordered Level 1/pureed diet due to dysphagia was served a banana that was only cut in half and left in the peel, rather than being pureed as required by the resident's diet order and meal ticket. The facility's own Diet/Texture Conversion Chart and national guidelines specify that foods on a pureed diet must be homogenous, cohesive, and pudding-like, with fresh bananas to be served well-mashed or pureed. During meal preparation, the surveyor observed that while other items on the resident's tray were properly pureed, the banana was not, and this was confirmed by both the Food Service Manager and a CNA, who acknowledged the error. The resident's care plan and physician orders documented the need for a pureed diet with honey-thickened liquids due to swallowing difficulties, edentulism, and nutritional risk. Despite these documented needs, the resident was served a banana in a form inconsistent with the prescribed diet. The surveyor observed the uneaten banana on the resident's bedside table after the meal, indicating it was not consumed. The deficiency was discussed with facility leadership during the survey process.
Failure to Maintain Food Safety and Hand Hygiene During Meal Preparation
Penalty
Summary
Food was not prepared and served in a sanitary manner for a resident on a mechanically-altered diet. Specifically, pureed foods prepared for the resident were served at temperatures below the required 135 degrees Fahrenheit, with recorded temperatures of 102, 106, and 108 degrees for various food items. The facility's policy requires hot pureed foods to be reheated to at least 165 degrees for 15 seconds if they fall below 135 degrees, but this was not done before the food was served to the resident. Additionally, improper glove use and hand hygiene practices were observed in the kitchen. The cook was seen changing gloves multiple times without washing hands between glove changes, and at one point, reused a glove after opening a drawer without handwashing or using a new glove. The facility's policy and training materials clearly state that hands must be washed before putting on gloves and between glove changes, but these procedures were not followed during food preparation.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Saint Francis
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Wheaton Franciscan Hc - Terrace At St Francis | 2.9 mi | ★★★★★ | 38 | 0 |
| St Ann Health And Rehabilitation Center | 3.7 mi | ★★★★★ | 11 | 0 |
| Autumn Lake Healthcare At Greenfield | 4.1 mi | ★★★★★ | 5 | 1 |
| Mercy Health Services | 4.1 mi | ★★★★★ | 3 | 0 |
| Maple Ridge Health Services | 4.2 mi | ★★★★★ | 0 | 0 |
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